Not upheld, no recommendations

Summary

C complained about the care and treatment provided to their friend (A) when they were admitted to hospital. A was in hospital for around three and a half months after being admitted with weakness and reduced mobility, with a short history of dysuria (pain or discomfort when urinating) and urinary urgency. A died during their stay in hospital.

C complained about several aspects of the nursing care provided to A. In addition to this, they complained about the physiotherapy input provided to A. Finally, C complained about what they considered to be insufficient detail in A’s death certificate.

In respect of the nursing care provided to A, the board acknowledged that there was learning or areas for improvement. We took independent nursing advice. We found that the board provided A with a reasonable standard of care. We recognised that there was learning to take from A’s experience, however, we did not consider that the care provided unreasonable. Therefore, we did not uphold this complaint.

In respect of the physiotherapy provided to A, we took independent physiotherapy advice. We found that the physiotherapy input provided to A was reasonable, given the circumstances at the time. Therefore, we did not uphold this complaint.

Summary

C complained that the board failed to provide them with appropriate orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) care and treatment following a fall. The board operated on C’s left wrist the day after the fall. Two days later, they performed revision surgery on C’s wrist and operated on their left elbow. C said that they had been advised by an orthopaedic surgeon at the board that their initial wrist surgery had not been done correctly. C said they had developed nerve compression pain issues and would require further surgery.

We took independent advice from an orthopaedic consultant. We found that C’s initial wrist surgery was reasonable. However, the tilt of the radius was slightly beyond the normal range, which carried a minor increased risk of longer term functional impairment in the wrist. We considered that, if C had not required additional surgery for the elbow, the initial wrist fixation might have been left unchanged, as any potential long-term dysfunction could still have been treated later if necessary. However, given that C was already scheduled for elbow surgery, the decision to proceed with revision surgery on the wrist was considered reasonable. We also noted that key indicators related to pain were appropriately assessed in C’s case, and there was no indication that the surgery had been performed in a manner likely to cause excessive pain. Therefore, we did not uphold C’s complaint.

Summary

C complained about communication from the council's social work department relating to C’s involvement in the Looked After Child (LAC) review process. C held parental rights and responsibilities for their child. C raised concerns about not being invited to attend a review meeting and not receiving a legible copy of a relevant report in advance of the meeting. In their response to the complaint, the council explained a watermark was incorrectly applied in the wrong font colour and apologised for this error.

We found that C was reasonably informed of the arrangements for the LAC review meeting and how they could contribute to it. In the month prior to the review meeting, the council’s Independent Reviewing Officer (IRO) contacted C. The role of an IRO is to work autonomously to manage and chair LAC reviews for children who are looked after and accommodated by the council. The IRO told C by email that there would be no option for C to attend the LAC review meeting, and C could submit their views via a proforma. C received a copy of the relevant report prior to the review meeting.

We found that the council had reasonably acknowledged, apologised for and rectified the error of the incorrectly applied watermark. Overall, we found that the provision of the relevant report, proforma that invited C’s views and email correspondence demonstrated that the council intentionally communicated with C in line with their responsibilities to seek the views of C as a person holding parental rights and responsibilities, in line with the relevant legislation and the council’s procedure. On this basis, we did not uphold this complaint.

Summary

C complained about the care and treatment provided to their spouse (A). A had been diagnosed with lung cancer and were due to start treatment. A had become unwell overnight and attended the A&E twice in 24 hours. At the first attendance A had been examined but sent home. A’s condition had worsened, and they had been taken back to the A&E by paramedics. A had been examined and then admitted to hospital but died shortly after.

C believed that A’s first assessment was inadequate, and that their concerns about pneumonia were dismissed unreasonably. They felt strongly that had A been given antibiotics and admitted, they might have had a better outcome. C believed that on A’s second attendance, A’s cancer specialists should have been contacted sooner.

We took independent advice from an emergency medicine adviser. We found that A’s assessments were reasonable and that it was unlikely that the outcome would have been different had A been prescribed antibiotics or admitted sooner. We did not uphold the complaint.

Summary

The complainant (C) had a right top hip replacement. Some years later, C began to experience back pain and left ankle pain for which they attended physiotherapists and podiatrists. C told us that two years after their hip replacement, a podiatrist identified that C had a leg length discrepancy. C complained that they now have a leg length discrepancy of approximately 17 mm which they considered to be unacceptable.

The board said that leg length discrepancy is a recognised risk following hip replacement surgery. This was confirmed on a form signed by C prior to the procedure.

We took independent advice from a consultant orthopaedic surgeon. We found that the risk of leg length discrepancy was reasonably discussed before the procedure and that the true discrepancy was 5mm which was reasonable. We noted that the operation was carried out to a reasonable standard.

As such, we found that the care and treatment provided by the board was reasonable and we did not uphold the complaint.

Summary

C complained on behalf of their spouse (A). A was taken into hospital with COVID-19 and low blood sugar and was discharged after two days. That night C was concerned that A’s condition had deteriorated. A was taken to ICU and died 4 days later. The cause of death was recorded as COVID-19, ketoacidosis (where a lack of insulin causes harmful substances called ketones to build up in the blood) and renal failure. C considered that A had been discharged inappropriately in the first instance.

The board explained that A was frail. They came into hospital with chest pains from COVID-19 and were checked for pulmonary embolism. A was discharged appropriately but unfortunately deteriorated rapidly at home. Every effort was made to treat A on readmission.

We took independent advice from a consultant physician, specialising in acute medicine. We found that A had a poor state of health prior to admission, that their discharge on the first occasion was reasonable and that there was no way the discharging team could have predicted A’s subsequent deterioration. Upon A’s second admission, medical teams and intensive care teams provided a reasonable standard of management and care. Overall, we considered that the care and treatment had been reasonable and that there was no requirement for a Severe Adverse Event Review or Duty of Candour to be initiated. Therefore, we did not uphold the complaints.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) that the board unreasonably prescribed A with Flutiform (a type of medication to treat asthma). A presented to hospital with symptoms of severe asthma and was admitted to the high dependency unit for management of their symptoms. Following assessment, A was prescribed with Flutiform. A’s symptoms improved and they discharged themselves from hospital.

A complained that Flutiform worsened their symptoms and should not have been prescribed, as they had previously suffered adverse reactions and informed the nurse of this during their assessment at the hospital. In their response to the complaint, the board said that Flutiform was prescribed in line with relevant guidelines and that there was no record of A having indicated that they had previous adverse reactions to Flutiform.

We took independent advice from a consultant physician in respiratory medicine. We found that whilst there is some record that Flutiform had not worked well for A, there was no evidence of an allergy in the clinical records. Whilst A recalled that they raised concerns about the use of Flutiform during the assessment, the contemporaneous assessment records, clinical records available at the time, and relevant guidelines supported the conclusion that there was no evidence against prescribing Flutiform to A. Therefore, we did not uphold C's complaint.

Summary

C complained on behalf of their child (A) about the care and treatment A received prior to their surgery. They complained that some procedures had been carried out during the surgery without parental consent. They also said that A had not been examined prior to the surgery and that they had been left with unnecessary scarring. The board stated that written consent had been provided on the day of the surgery and the clinical notes recorded the procedures to be carried out and the risks of surgery had been explained at that time. The board also stated that A had been examined. However, they apologised if the verbal discussion prior to the operation had not prepared C for the outcome and also apologised if some of the scarring following the surgery was unsightly.

We took independent advice from a consultant paediatric urologist (specialist in children's urinary and genital problems). We found that the evidence suggested that the signed consent form had been read by C prior to the surgery and that no unnecessary procedures had been carried out. While there were no records to prove or disprove that A had been examined on the day of the surgery on balance we considered it was likely that A had been examined preoperatively. Although ideally it should have been explained to C during the consent process that there was a possibility that redistribution of the skin could be required during the operation, we found that it was not unreasonable that this was not mentioned. We also found that the care and treatment A had received on the day of the surgery was reasonable and that there was no evidence that the surgery carried out was inappropriate or excessive. Therefore, we did not uphold C’s complaints.

Summary

C complained about the care and treatment provided by the board during and after the birth of their child. Following the birth of their child, C received a perineal (space between the anus and vagina) repair. C complained that the stitching was incorrectly carried out and that this subsequently caused ongoing pain and tightening of the vagina. At a consultation with a gynaecologist (specialist in the female reproductive system) the following year, it was identified that C had a thick band of skin at the vaginal opening. There was also a concern about pelvic floor muscle tightness which indicted vaginismus (an involuntary tensing of the vagina when something is inserted into it). C was referred to physiotherapy. As this was not successful, an operation to remove the thick band of skin was undertaken with the explanation that it was unlikely to improve the tightness of the muscles. C was also referred for psychosexual counselling.

C complained that they did not receive a follow-up after the operation and that they had not received an appointment for psychosexual counselling. The board reassured C that their perineal repair was performed correctly. However, they explained that unfortunately vaginismus can occur after any vaginal repair procedure. They noted that it was not always standard practice to follow up patients after gynaecology surgery but C had been added to the routine waiting list which was approximately one year. The waiting time for a psychosexual counselling appointment was 91 weeks. They apologised for C’s wait.

We took independent advice from a consultant gynaecologist. We found that the perineal repair was reasonable and that the decision to offer physiotherapy, then the operation was reasonable. It was also reasonable to refer C for psychosexual counselling. Offering a follow-up review was not standard after elective gynaecological surgery. We considered that care and treatment, from the birth until the operation, was reasonable. We acknowledged that waiting times had been extended. However, we accepted the advice received. We noted that treatment time standards do not cover routine post-operative reviews or psychosexual counselling. Therefore, we did not uphold C's complaint.

Summary

C complained about the care and treatment provided to their parent (A). A was admitted to hospital (Hospital 1) following a period of delirium which was a result of a urinary tract infection (UTI). They were treated with antibiotics but their delirium continued. A was transferred to another hospital for a period of rehabilitation (Hospital 2). C said that a nurse refused to take a urine test when A was showing symptoms of a further UTI, on the basis that A had no temperature. C also complained about a delay in prescribing antibiotics. A’s condition deteriorated again during their admission. C asked for a doctor to be called but they were told that no doctors were available. A deteriorated further that night and required admission to Hospital 1, where they died the following day.

C complained that A was denied access to a doctor. They also complained about communication and a lack of compassion from staff. A’s admission was during a time when visiting was restricted because of COVID-19 guidelines. C complained that staff should have allowed more frequent access to A when A was confused and distressed.

We took independent clinical advice from a consultant geriatrician (specialist in medicine of the elderly). We found that A’s symptoms were not sufficiently clear to have merited a prescription of antibiotics sooner than they were prescribed. We noted that deterioration in older frail adults is often unpredictable and rapid, and found no failings in care and treatment provided to A. Based on the information available, we found no failings in communication, although we noted that the board had apologised to C already for certain communication failings. We found that staff were following the appropriate policies for visiting.

Therefore, we did not uphold C's complaint.